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Trust for America's Health

Docs Should Play Role in Increasing Immunization Uptake in Adults

By David Mitchell
3/8/2010

According to a new report from the Trust for America's Health, up to 50,000 U.S. adults die each year from vaccine preventable diseases, and the direct health care burden of vaccine preventable diseases in American adults is $10 billion a year. Physicians, however, can help increase uptake levels for adult vaccinations by making the most of office visits with these patients to get them immunized.

The nation's high immunization rate in children is the product of a long-term commitment, said William Schaffner, M.D., chairman of the Infectious Diseases Society of America's Immunization Work Group and co-author of the report "Adult Immunizations: Shots to Save Lives" during a media event to announce the report. But it is time to extend that commitment "beyond the 19th birthday."

According to Schaffner, professor and chair of the department of preventive medicine at Vanderbilt University School of Medicine, the vast majority of vaccine-preventable disease, hospitalizations and deaths in the United States occur among adults. "The country has an absolutely stunningly first-rate system for immunizing children, but too many adults still fall through the cracks," he said. "It's really time to build a better strategic approach for systematically immunizing adults."

The report found that uptake is extremely low among adults for several recommended vaccines. For example, only 2.1 percent of U.S. adults aged 18-64 have received the tetanus toxoid, reduced diphtheria toxoid and acellular pertussis, or Tdap, vaccine. Less than 2 percent of adults aged 60 and older have received the herpes zoster vaccine.

The report suggests that physicians could play a large role in preventing disease and lowering health care costs by increasingly encouraging their adult patients to get vaccinated. The report recommends that

physicians make it standard practice to review patients' immunization histories and offer vaccinations during appropriate medical encounters, such as cancer screenings and prenatal visits;
hospitals and medical practices promote the use of standing orders for vaccinations;
physicians use electronic medical records and immunization registries to improve information sharing among physicians and to generate reminders to physicians and patients about recommended vaccinations; and
health care workers reduce transmission of disease and set an example by complying with immunization recommendations, including annual flu vaccinations.

In a recent AAFP member survey, 64 percent of respondents said they use standing orders for adult patients. The policy is used most commonly for influenza vaccinations; 83 percent of members said they have standing orders for flu vaccines. The figure dropped to 49 percent for pneumococcal vaccine, which was one of the areas of concern highlighted in the report.

As for health care worker immunizations, AAFP members report that 92 percent of their employees are routinely immunized against influenza, and 88 percent report that their employees were immunized against Hepatitis B. However, less than half (42 percent) report that their staffs have been immunized with the Tdap vaccine.

Setting a Good Example

A recent report from the Trust for America's Health suggests that health care workers can reduce transmission of disease and set an example for patients by complying with the following immunization recommendations from the CDC's Advisory Committee on Immunization Practices and the AAFP.

Health care personnel, who can cause flu outbreaks among patients and long-term care residents, should be vaccinated for influenza every year.
Hepatitis B vaccine should be given to protect workers who are in contact with blood, body fluids or used needles.
Health care workers who are not already immune to measles, mumps and rubella should receive the MMR vaccine. Even mild or undetectable rubella disease can cause birth defects.
Health care workers need a booster dose every 10 years for tetanus and diphtheria, or Td, vaccine. The tetanus toxoid, reduced diphtheria toxoid and acellular pertussis, or Tdap, vaccine should replace a single dose of Td for adults who have not received a dose of Tdap previously.
Health care workers who are not already immune should receive two doses of varicella vaccine.

The Trust for America's Health report acknowledges that several obstacles for both physicians and their patients hinder increasing uptake levels. Although children often must have recommended immunizations to enroll in school, only a few groups of adults, including college students and the military, have to meet similar requirements.

Furthermore, some private insurance companies do not cover adult vaccines and administration costs; Medicaid coverage varies by state. Provider limitations and challenges related to storing vaccine and patient concerns about safety and effectiveness are factors as well, according to the report.

"This country does not have an effective strategy for immunizing adults against infectious diseases," Jeffrey Levi, executive director of Trust for America's Health, said during the media briefing. "Thousands of lives could be saved each year if we could increase the number of adults who receive routine and recommended vaccinations. We need a national strategy to make vaccines a regular part of medical care and to educate Americans about the effectiveness and safety of vaccines."

The report offers several recommendations regarding insurance issues and government funding, including calling for

increased funding for the Section 317 program, which provides vaccines to underinsured children, adolescents, and to a lesser extent, uninsured and underinsured adults;
the creation of a Vaccines for Uninsured Adults program that would be similar to the CDC's Vaccines for Children program;
coverage of all recommended vaccines under Medicare Part B, rather than the current system which has some vaccines under Part B and others under Part D;
private payers to cover all recommended vaccines using administration fees covered by Medicare Part B as a minimal standard; and
additional congressional support of research into adult vaccines and increased support for state and local health departments.

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